Entry Survey

First name

Last name

I feel my wellbeing is

VERY POOR and this has a PROFOUND NEGATIVE impact on my daily life

QUITE POOR and this has a NEGATIVE impact on my daily life

OKAY and only SOMETIMES NEGATIVELY impacts my daily life

QUITE GOOD and only OCCASIONALLY NEGATIVELY impacts my daily life

VERY GOOD and RARELY IF EVER NEGATIVELY impacts my daily life

How I feel about manging my home

I know NOTHING about managing my home

I know A LITTLE about managing my home

I have REASONABLE KNOWLEDGE about managing my home

I have GOOD KNOWLEDGE about managing my home

I have VERY GOOD KNOWLEDGE about managing my home

I feel my family wellbeing is

VERY POOR and this has a PROFOUND NEGATIVE impact on my daily life

QUITE POOR and this has a NEGATIVE impact on my daily life

OKAY and only SOMETIMES NEGATIVELY impacts my daily life

QUITE GOOD and only OCCASIONALLY NEGATIVELY impacts my daily life

VERY GOOD and RARELY IF EVER NEGATIVELY impacts my daily life

I describe my connection to the community as

I am VERY ISOLATED. I have VERY LITTLE contact with friends, family or people in the community

I am FAIRLY isolated. I have LITTLE contact with friends, family, or people in the community

I feel SOMEWHAT connected. I have SOME contact with friends, family, or people in the community

I feel FAIRLY connected. I have a REASONABLE amount of contact with friends, family, or people in the community

I feel VERY connected. I have A LOT of contact with friends or family, or people in the community

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